NSG 200 Exam 1
SBAR - ANS-S: Situation (patient's basic info)
B: Background (comorbidity, social factors, allergies)
A: Assessment (pertinent abnormal finding found in head to toe assessment)
R: Recommendation(problems with the most priority first, any precautions, and any isolations)
*form of communication between health personnel*
DAR - ANS-D: Data (subjective and objective data)
A: Action (document all nursing data)
R: Response (record patients response to therapy)
*form of documentation*
SOAP - ANS-S: subjective (what patient tells you)
O: objective (what you observe and see)
A: Assessment (what you think is going on based on your data)
P: plan (what you're going to do)
Can also be added to better reflect nursing process:
I: intervention (specific interventions implemented)
E: evaluation (patient's response to interventions)
R: revision (changes in treatment)
*form of documentation*
Subjective Data - ANS-what the person says about themselves (biographic Information, past
history, lifestyle, etc.)
objective data - ANS-what you obtain through physical examination (posture, physical
appearance, ability to carry a conversation, overall demeanor, etc.)
Phase of Interview process: Introduction - ANS-introduce yourself, your role, explain purpose of
examination, explain how data will be gathered and used, discuss with patient other pertinent
matters
Phase of interview process: Working - ANS-gather data, use open-ended questions which ask
for narrative information, used closed/ directive questions which ask for specific information
inshore one-two word answers.
, *this is when comprehensive and the health history is gathered*
Phase of interview process: Closing - ANS-signal interview is closing, summarize what you've
learned, review data/ make corrections, discuss possible plans to resolve symptoms, answer
patients questions/ concerns
Communication techniques: internal factors - ANS-liking others, expressing empathy, ability to
listen, self-awareness
Communication techniques: external factors - ANS-ensure privacy, prevent interruptions, create
a conducive environment, equal status seating, wear appropriate attire, document response
without interfering with conservation
Communication techniques: facilitation - ANS-encourage patient to say more, general leads,
minimal cues, reflection, empathy, clarification, repeat what patient says back to them
*clients perspective*
communication techniques: confrontation - ANS-clarify inconsistent information
*examiners perspective*
communication techniques: interpretation - ANS-link events, make associations, your
interpretations might be incorrect but prompts more answers
*examiners perspective*
communication techniques: explanation - ANS-inform client what you're saying
*examiners perspective*
communication techniques: summary - ANS-condense everything such as pertinent facts
*examiners perspective*
communication barriers - ANS-false reassurance/ reassurance, unwanted advice,
developmental, language, distancing, professional jargon, leading-biased questions
Comprehensive assessments - ANS-one time only, done when patient is first admitted
Emergent assessments (ABCD) - ANS-A: airway (chocking/ blocked)
B: breathing (asthma/ lungs)
C: circulation (hypotensive, mentation/ alertness way down, bleeding uncontrollably)
D: neurological deficit (stroke)
SBAR - ANS-S: Situation (patient's basic info)
B: Background (comorbidity, social factors, allergies)
A: Assessment (pertinent abnormal finding found in head to toe assessment)
R: Recommendation(problems with the most priority first, any precautions, and any isolations)
*form of communication between health personnel*
DAR - ANS-D: Data (subjective and objective data)
A: Action (document all nursing data)
R: Response (record patients response to therapy)
*form of documentation*
SOAP - ANS-S: subjective (what patient tells you)
O: objective (what you observe and see)
A: Assessment (what you think is going on based on your data)
P: plan (what you're going to do)
Can also be added to better reflect nursing process:
I: intervention (specific interventions implemented)
E: evaluation (patient's response to interventions)
R: revision (changes in treatment)
*form of documentation*
Subjective Data - ANS-what the person says about themselves (biographic Information, past
history, lifestyle, etc.)
objective data - ANS-what you obtain through physical examination (posture, physical
appearance, ability to carry a conversation, overall demeanor, etc.)
Phase of Interview process: Introduction - ANS-introduce yourself, your role, explain purpose of
examination, explain how data will be gathered and used, discuss with patient other pertinent
matters
Phase of interview process: Working - ANS-gather data, use open-ended questions which ask
for narrative information, used closed/ directive questions which ask for specific information
inshore one-two word answers.
, *this is when comprehensive and the health history is gathered*
Phase of interview process: Closing - ANS-signal interview is closing, summarize what you've
learned, review data/ make corrections, discuss possible plans to resolve symptoms, answer
patients questions/ concerns
Communication techniques: internal factors - ANS-liking others, expressing empathy, ability to
listen, self-awareness
Communication techniques: external factors - ANS-ensure privacy, prevent interruptions, create
a conducive environment, equal status seating, wear appropriate attire, document response
without interfering with conservation
Communication techniques: facilitation - ANS-encourage patient to say more, general leads,
minimal cues, reflection, empathy, clarification, repeat what patient says back to them
*clients perspective*
communication techniques: confrontation - ANS-clarify inconsistent information
*examiners perspective*
communication techniques: interpretation - ANS-link events, make associations, your
interpretations might be incorrect but prompts more answers
*examiners perspective*
communication techniques: explanation - ANS-inform client what you're saying
*examiners perspective*
communication techniques: summary - ANS-condense everything such as pertinent facts
*examiners perspective*
communication barriers - ANS-false reassurance/ reassurance, unwanted advice,
developmental, language, distancing, professional jargon, leading-biased questions
Comprehensive assessments - ANS-one time only, done when patient is first admitted
Emergent assessments (ABCD) - ANS-A: airway (chocking/ blocked)
B: breathing (asthma/ lungs)
C: circulation (hypotensive, mentation/ alertness way down, bleeding uncontrollably)
D: neurological deficit (stroke)
